Name

First name

Last name

Create Your Password

Password (case sensitive, must be at least 5 characters) 5 or more chars

Confirm password (case sensitive, must be at least 5 characters)

Email (This will become your User ID)

School / organization email

Confirm school / organization email

Work phone

Extension (optional)

Please choose the closest title to your job role
School Nurse (RN/NP) Licensed Practical Nurse (LPN) School Medical Director (MD/DO/NP) School Mental Health Provider (SW/Counselor/Psychologist) School Health Educator/Coordinator School Administrator Other

If you selected "Other," please enter your role or title (optional)

Type of School
BOCES Charter Nonpublic/Private Public

Region
Capital (Albany/Columbia/Greene/Saratoga/Schenectady/Rensselaer/Warren/Washington) Central (Cayuga/Cortland/Madison/Onondaga/Oswego/Tompkins) Finger Lakes (Genesee/Livingston/Monroe/Ontario/Orleans/Seneca/Wayne/Wyoming/Yates) Long Island (Nassau/Suffolk) Mid-Hudson (Dutchess/Orange/Putnam/Rockland/Sullivan/Ulster/Westchester) Mohawk Valley (Fulton/Hamilton/Herkimer/Montgomery/Oneida/Schoharie) New York (Bronx/Kings/Queens/New York/Richmond) North Country (Clinton/Essex/Franklin/Jefferson/Lewis/St. Lawrence) Southern Tier (Broome/Chemung/Chenango/Delaware/Otsego/Schuyler/Steuben/Tioga) Western (Allegany/Cattaraugus/Chautauqua/Erie/Niagara)

School District

School/Organization Name

School/Organization Street Address

School/Organization City

School/Organization Zip Code